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States tackle health care issues through election initiatives

Voters say no to physician-assisted suicide in Michigan, approve medical uses of marijuana in five states

From the December 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Although health care issues fizzled in this year's Congress, they frequently took center stage in last month's local elections.

In North Carolina, Democrat John Edwards defeated an incumbent Republican senator, in part by promising to allow patients who have been denied care to sue their health plans. And Wisconsin Democrat Tammy Baldwin won a seat in the House after calling for full health care coverage for all of the state's citizens.

But most of the real action occurred in local-level initiatives that tackled complex issues such as physician-assisted suicide, medical marijuana and access to care.

Physician-assisted suicide

While Jack Kevorkian, MD, was not directly involved in the discussion surrounding Michigan's Proposal B, officially known as the Merian's Friends Physician Assisted Suicide Initiative, his highly publicized assisted suicides in the state certainly colored the debate. Analysts say that nearly three-quarters of Michigan voters rejected the proposal, in part because it asked voters to approve a cumbersome 48-page law that would have allowed physicians to prescribe lethal doses of medication, and also because the proposed law would have imposed criminal penalties on physicians.

According to Cathy O. Blight, MD, president of the Michigan State Medical Society, which fought Proposal B, the initiative would have established an "end-of-life bureaucracy" to determine which patients were eligible for assisted suicide. Under the proposal, two physicians would have had to rule that a patient was terminally ill and a psychiatrist would have had to judge the patient's mental competency.

The proposal would have also treated physicians harshly. Doctors who did not inform patients of their unwillingness to assist with suicide and transmit copies of medical records to another doctor of the patient's choice within 72 hours could have been fined or imprisoned. Physicians who failed to keep patient records for three years detailing their compliance with the proposal's requirements would also have faced fines or prison. And physicians who treated terminally ill patients with large doses of pain medication that helped hasten their deaths could have faced fines of $50,000, imprisonment for up to five years, or both.

"That would discourage physicians from providing effective palliative care to their terminally ill patients who are not seeking assisted suicide," Dr. Blight said.

In the election's aftermath, the state medical society and the coalition it helped form hope to launch a major educational effort on end-of-life care targeting both physicians and the general public. Dr. Blight emphasized that the society opposed Proposition B's specific flaws, not the overall idea of physician-assisted suicide as an ethical concern. "We have physicians on both sides, and there's debate just about every year in our House of Delegates," she said.

Medical marijuana

With financial backing from the New York-based Lindesmith Center, a research project funded in part by billionaire George Soros, medical marijuana initiatives were placed on seven state and district ballots—and won.

More than half of those voting approved measures to legalize the use of marijuana for medical purposes in five different states: Alaska, Arizona (voters there upheld a similar measure passed in 1996), Nevada, Oregon and Washington. An initiative in Colorado was ruled invalid at the last minute because of a technicality involving petition signatures, though exit polls showed it passing with 61%. At press time, the results of the Washington, D.C., initiative had not been released, but exit polls showed its measure passed 69% to 31%.

Despite support from voters in a number of states, there is disagreement within the medical community. Although The New England Journal of Medicine last year came out in favor of medicalizing marijuana, The National Medical Association Inc. (NMA), the nation's oldest African-American medical professional organization, actively lobbied against the passage of last month's initiatives.

Gary C. Dennis, MD, the NMA's president, said that while marijuana is viewed as a substance to help patients suffering from certain types of illnesses, those uses have not undergone necessary clinical trials or been approved by the FDA. But even more important, he said, marijuana has devastating side effects and is a gateway drug "that contributes significantly to morbidity, especially among African Americans." Dr. Dennis warned that developments in states with new marijuana laws should be closely watched.

"These initiatives put doctors in a compromising predicament," he said. "Physicians now become responsible for treatment decisions that have unanswered social and regulatory issues."

Bill Zimmerman, PhD, director of Americans for Medical Rights, an advocacy group that sponsored several of the new initiatives, countered that a great deal of peer-reviewed research, published primarily in the 1970s, supports the medical uses of marijuana. The FDA has not approved the medical use of marijuana, he acknowledged, "but that's been much more for political than for scientific reasons."

Nonetheless, Americans for Medical Rights has learned some important lessons. In California, voters passed an initiative in 1996 authorizing doctors to recommend marijuana for the treatment of any patient or condition. Because marijuana remains illegal at the federal level, physicians who recommended the drug for medical purposes were concerned that they would be threatened with the loss of licensure and other sanctions by federal organizations.

Several of the new initiatives establish a different procedure. Patients in Alaska, Nevada and Oregon who want marijuana for medical purposes must apply to their state governments for an identification card which will exempt them from arrest for possession. To get such a card, they must produce a letter from their doctor with the physician's diagnosis and a statement from the physician saying that he has explained the risks and the potential benefits of marijuana to the patient.

Unlike the initiative passed in California, several of the initiatives passed last month also restrict the medical use of marijuana to patients undergoing chemotherapy for treatment of cancers and patients with the following conditions: AIDS; glaucoma; seizure disorders, such as epilepsy; and muscle spasticity disorders.

Neither doctors nor patients have been arrested in California, but marijuana buying clubs—a safe haven for patients that kept them away from drug dealers—have been closed by state and federal authorities. How marijuana will be delivered to patients in states with new medical marijuana laws remains to be seen, but initiatives in other states are already certain. One is expected to be on the ballot in Maine in 1999, while the effort in Colorado will be reprised in 2000.

Cook County landslide for universal access

In Cook County, which contains more than half of all registered voters in Illinois, 83% of voters last month endorsed what has come to be known as the Bernardin Amendment. Cardinal Joseph Bernardin, the archbishop of Chicago who died in 1996, made universal coverage a goal of his ministry. Language from two of his pastoral letters, claiming that "health care is an essential safeguard of human life and dignity," was used to draft a constitutional amendment to provide universal health care coverage to everyone in the state, the beginning of a grueling process.

The ballot must be passed by other voters throughout the state, then passed by 60% of the state congress and 60% of the general electorate before the state constitution can be changed, but supporters of universal access are encouraged. "This is the first step in a long journey," said Quentin D. Young, MACP, national coordinator for the Physicians for a National Health Program.

Warren F. Furey, FACP, Governor for the Illinois Northern Chapter and Cardinal Bernardin's personal physician, described the development as "wondrous." The campaign and the amendment's clear mandate were very gratifying, he said. "Now, let's keep it going."

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